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TOXICS USli 
REDUCTION 
INSTITUTE 




THE MASSACHUSETTS 

TOXICS USE REDUCTION INSTITUTE 



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^OVtRN^/ltNT DOCUMENTS 



OCT 2 V 1999 

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FORMALDEHYDE USE REDUCTION 

IN MORTUARIES 

■ \ 



Technical Report No. 24 



1994 



University of Massachusetts Lowell 



Formaldehyde Use Reduction 
in Mortuaries 



Chengchen Mao 
Sc.D Candidate, Work Environment Department 

Professor Susan Woskie 
Work Environment Department 



University of Massachusetts Lowell 



The 1993 - 1994 Toxics Use Reduction Research Fellows Program 



The Toxics Use Reduction Institute 
University of Massachusetts Lowell 

1994 



All rights to this report belong to the Toxics Use Reduction Institute. The 
material may be duplicated with permission by contacting the Institute. 

The Toxics Use Reduction Institute is a multi-disciplinary research, education, 
and policy center established by the Massachusetts Toxics Use Reduction Act of 
1989. The Institute sponsors and conducts research, organizes education and 
training programs, and provides technical support to promote the reduction in 
the use of toxic chemicals or the generation of toxic chemical byproducts in 
industry and commerce. Further information can be obtained by writing the 
Toxics Use Reduction Institute, University of Massachusetts Lowell, One 
University Avenue, Lx)well, Massachusetts 01854. 



®Toxics Use Reduction Institute, University of Massachusetts Lowell 



Toxics Use Reduction Institute 
Research Fellows Program 



In 1991, the Toxics Use Reduction Institute established the Research Fellows Program at the 
University of Massachusetts Lx)well (UML). The Research Fellows Program funds toxics use 
reduction projects performed by a graduate student and his/her advisor. The goals of the 
Research Fellows Program are: 

• to develop technologies, materials, processes, and methods for implementing toxics use 
reduction techniques 

• to develop an understanding of toxics use reduction among UML graduate students and 
faculty 

• to facilitate the integration of the concept of toxics use reduction into UML research 
projects 

to provide UML faculty with "incubator" funding for toxics use reduction related 
research, and 

• to act as a liaison between Massachusetts industries and UML faculty. 



Notice 

This report has been reviewed by the Institute and approved for publication. Approval does 
not signify that the contents necessarily reflect the views and policies of the Toxics Use 
Reduction Institute, nor does the mention of trade names or commercial products constitute 
endorsement or recommendation for use. 



Digitized by the Internet Archive 

in 2015 



https://archive.org/details/fornnaldehydeuserOOnnaoc 



FORMALDEHYDE USE REDUCTION IN MORTUARIES 



ABSTRACT 



Funeral services may be seen as the final phase of the health care system in human 
society. The history of embalming, or preserving human bodies, goes back to 4000 B.C. The use 
of formaldehyde for fixation and preservation of the body for funeral services has had 
widespread use since its tissue-hardening properties were discovered in 1893. In 1993, there 
were 960 funeral homes distributed throughout the Commonwealth of Massachusetts, which 
were staffed with 2,400 licensed morticians. It is estimated that approximately 249,920 gallons 
of embalming fluids containing approximately 180,163 pounds (26,492 gallons) of formaldehyde 
are consumed each year by mortuaries in this state. The embalmers are exposed to formaldehyde 
and its polymers during the course of their work. The options for toxics use reduction (TUR) of 
formaldehyde in funeral services should include modification of societal behavior, changes in 
state legislation to allow the elimination of unnecessary embalming, and the use of embalming 
fluids with lower concentrations of formaldehyde. In addition, an embalming fluid where 
formaldehyde has been replaced by an ethyl alcohol-polyethylene glycol combination is a 
potential alternative for mortuaries to consider. 



1 



TABLE OF CONTENTS 



ABSTRACT 1 

I. PROJECT DESCRIPTION 3 

II. RESEARCH METHODOLOGY 4 

Phase I. Scope and definition of the problem 4 

Phase II. Identification of Toxic Use Reduction Options 4 

III . RESULTS OF LITERATURE SEARCHES 5 

Health Effects of Formaldehyde 5 

Occupational Exposure in Funeral Services 9 

Historical Profile of the Practice of Embalming in Funeral Service 10 

IV. EMBALMING PROCESS DESCRIPTION 13 

Procedures and Processes of Embalming 13 

Estimation of Facilities and Working Population 14 

V. OPTIONS FOR FORMALDEHYDE USE REDUCTION 15 

Modification of Societal Behavior and Legislative Changes 15 

Alternate Technologies for Preservation of the Human Body 16 

Substitution or Reduction of Formaldehyde Use in Embalming 17 

Minimization of Formaldehyde Release 19 

VI. CONCLUSIONS AND RECOMMENDATIONS 19 

BIBLIOGRAPHY 21 



2 



I. PROJECT DESCRIPTION 



Exposure to formaldehyde has three types of health effects—irritation, immunologically 
mediated sensitization, and carcinogenicity (Moore and Ogrodnik, 1986 and OSHA, 1992). 
Formaldehyde is on the Hazardous Substance List and regulated by the Occupational Safety and 
Health Administration (OSHA, 1992) and the Environmental Protection Agency (EPA, 1984). 
The National Institute for Occupational Safety and Health (NIOSH, 1976) and the American 
Conference of Governmental Industrial Hygienists (ACGIH, 1983) have also recommended 
standards for exposure to formaldehyde. In addition, formaldehyde is considered a toxic 
chemical by the Emergency Planning and Community Right-To-Know Act (EPCRA) (U.S. 
Environmental Protection Agency, 1 986) at the federal level and by the Toxics Use Reduction 
Act (TURA) in Massachusetts (The State of Massachusetts, 1989). 

The history of embalming, or preserving human bodies, goes back to 4000 B.C. 
(McDonald, 1989). Embalming practice started as a simple treatment of the body with herbs 
(before 4000 B.C.) and developed into a complex procedure using chemical solutions in the late 
1600's. In the nineteenth century, techniques were developed for infusion of embalming fluid 
into the vascular system. Formaldehyde has been used as a preserving and embalming agent 
since its tissue-hardening properties were discovered in 1893 (Bjorkman, et al, 1986). In 
embalming, the three main procedures are disinfection, preservation, and restoration of the 
human remains prior to funeral services. During the course of their work, embalmers are exposed 
to formaldehyde and its polymers. Personal exposures to formaldehyde in mortuaries have been 
documented as 0.5 to 8.72 ppm (Walrath, et al, 1983, Williams, et al., 1984, Moore and 
Ogrodnik, 1986, Stewart, et al, 1992 and Korczynski, 1994). 

Preuss et al, (1985) indicated that the embalming and funeral service industry had the 
largest number (2.6 million) of employees among the job categories with formaldehyde 
exposures in the United States. Gressel and Hughes (1992) reported that there were 75,000 
employees working in over 20,000 mortuaries in this country. Formaldehyde use and exposure in 
funeral services in Massachusetts has not been documented in the published literature. The 
consumption of formaldehyde by the funeral industry, and the number of mortuary workers 
exposed to formaldehyde in Massachusetts is not available from any public source. 

This project was designed: 1) to outline population patterns of exposure to formaldehyde 
embalming fluids, 2) to identify both currently available and possible means for reducing 
formaldehyde use in mortuary environments, and 3) to assess feasibility of implementing the 
toxic use reduction options for formaldehyde in embalming. 



3 



II. RESEARCH METHODOLOGY 



Phase I. Scope and definition of the problem 

The number of mortuary facilities, the quantity of formaldehyde fluid used, and the 
number of exposed persons were ascertained. The number of funeral homes and licensed 
morticians in Massachusetts were obtained from the Massachusetts Board of Registration in 
Embalming and Funeral Directing. With this data and information from personal interviews at 
the National Center for Death Education at Mount Ida College and the Massachusetts Funeral 
Directors Association, the total population exposure to formaldehyde in funeral homes was 
estimated. 

The number of deaths in Massachusetts in 1 992 was obtained from the Massachusetts 
Department of Public Health. Estimation of the amount of embalming fluid used in each dead 
body and the concentration of embalming fluid was based on literature from the Dodge Chemical 
Company, the National Center for Death Education at Mount Ida College, and the Massachusetts 
Funeral Directors Association. The total amount of formaldehyde consumed each year by funeral 
homes in Massachusetts was estimated by multiplying the quantity of formaldehyde used for 
each body and the number of deaths in the state. 

The specific procedures used in mortuary operations were documented by visiting the 
mortuaries and interviewing morticians. To facilitate TUR option assessment, the procedures 
were stratified into process steps and placed in a model of causal sequences (see Figure I), in 
which the hazard of formaldehyde exposure is a result of a series of events, each with 
consequences. By examining the events and consequences which produce the hazard, three 
possible strategies for hazard control emerge: a) prevention of events leading to hazard; b) 
prevention of consequences once events have taken place; and c) mitigation of consequences. 
Prevention of events is the most desirable strategy, whereas mitigation is regarded as least 
desirable. By using this broader view of the hazard, a wider range of TUR options is possible. 
For example, an examination of the social, public health, and legal history of embalming may 
produce alternate formaldehyde reduction approaches. 

Phase II. Identification of Toxic Use Reduction Options 

Several possibilities for formaldehyde use reduction were examined through library 
research, interviews, and mortuary visits. Based on the social, public health, and legal history of 
the use of formaldehyde embalming fluids, options for alternate burial and mortuar>' procedures 
were investigated and evaluated. Possible substitution of less or non-toxic chemicals for 
formaldehyde in embalming fluids was investigated. Through a literature search and interviews 
with a local manufacturer of embalming fluids and the personnel at the National Center for 
Death Education at Mount Ida College, chemical substitutes for formaldehyde in embalming 



4 



fluids were investigated. In addition, engineering and work practice interventions were 
investigated as ways to reduce formaldehyde use and release during embalming. 



Ill . RESULTS OF LITERATURE SEARCHES 

Formaldehyde is a colorless, noxious, and readily polymerized gas at normal temperature. 
It has a strong, pungent, and irritating odor. Its molecular weight is 30.03. The most common 
commercially available form is a 30-50% aqueous solution. Methanol or other substances are 
usually added to the solution as stabilizers to reduce polymerization. Formaldehyde is soluble in 
alcohols and ether, and very soluble in water (up to 55 g/100 ml) ( Stewart et al., 1992). In the 
presence of air and moisture at room temperature, formaldehyde readily polymerizes to a 65-70% 
formaldehyde-air mixture, which is readily flammable (WHO, 1 989). Formaldehyde decomposes 
into methanol and carbon monoxide at temperatures above 150 ° C. Under atmospheric 
conditions, formaldehyde is photo-oxidized in sunlight to carbon dioxide. Its half-life is 
approximately 50 minutes during the daytime, but in the presence of nitrogen dioxide, this drops 
to about 30 minutes (Bufalini et al., 1972). 

Health Effects of Formaldehvde 

Exposure to formaldehyde has three types of health effects —irritation, immunologically 
mediated sensitization, and carcinogenicity (Moore and Ogrodnik, 1986, Hathaway, et al., 1991, 
and OSHA, 1992). The acute and chronic respiratory function effects of formaldehyde are 
unclear at this time. Liquid formaldehyde may irritate the skin, causing a rash or burning feeling 
on contact. It can also cause severe bums, leading to permanent damage. Because of its chemical 
reactivity and high water solubility, formaldehyde exposure irritates the nose, mouth and throat. 
Exposure to high concentrations of formaldehyde in air can cause a build-up of fluid in the lungs 
or spasms of the windpipe, and edema of the larynx. It has been shown to cause cancer of the 
nasal passages in animals. Allergic reactions and superficial coagulative necrosis have been 
associated with formaldehyde exposures (ACGIH, 1992). Lightheadeness, dizziness and 
diminished dexterity have been found among histology laboratory employees exposed to 
formaldehyde (Kilbum et al., 1987). Formaldehyde has been identified by OSHA (1992) and 
EPA (1984) as a Probable Carcinogen in humans. 

The adverse health effects of formaldehyde in animals have been reviewed by the 
National Research Council (1981). Literature reviews of the health effects of formaldehyde were 
also conducted by the National Institute for Occupational Safety and Health (NIOSH, 1976), the 
Occupational Safety and Health Administration (OSHA, 1987), the American Conference of 
Government Industrial Hygienists (ACGIH, 1992), and the American Industrial Hygiene 
Association (AIHA, 1989). The health effects of formaldehyde reported in this paper are mainly 



5 



based on these reviews. 

Irritation of the upper respiratory tract is the major characteristic of the non-cancer health 
effects of formaldehyde. Sensory irritation with acute inhalation exposures is concentration 
dependent and has been well documented by NIOSH (1976). Irritation of the eyes. nose, throat, 
and cellular changes in the upper respiratory tract have been found in animals exposed to 
formaldehyde aerosol. Itching of the eyes, dry and sore throat, disturbed sleep, and unusual thirst 
were reported among workers exposed to formaldehyde air concentrations ranging from 0.9 to 
1.6 ppm (Morrill, 1967). The National Research Council (NRC, 1981) concluded that eye 
irritation was a common symptom of formaldehyde exposure and that human eyes are very 
sensitive to formaldehyde vapor. Eye irritation was documented at concentrations as low as 0.01 
ppm formaldehyde, although eye irritation in most cases was observed between 0.05 ppm and 0.5 
ppm formaldehyde. 

Horvath et al (1988) indicated that 3% to 5% of the workers exposed to formaldehyde 
during particle board manufacturing complained of sore throats at formaldehyde concentrations 
of 0.05 ppm compared to 3.9% in the control groups. At higher concentrations, more exposed 
individuals complained, with 22% complaining at concentration levels from 0.4 to 1.0 ppm and 
34% complaining at exposures of greater than 1 .0 ppm of formaldehyde. A significantly (P < 
0.001) higher proportion of the particle board employees, when compared with the control 
groups, complained of eye irritation (43% versus 23%) as well as nose and throat irritation (31% 
versus 5%). Dossing (1982) reported that women exposed at 0.43 mg/m^ of formaldehyde had 
more frequent eye irritation than a matched control group. 

The health effects of formaldehyde on respiratory function have been addressed recently, 
but a consistent conclusion has not been reached. Several studies have looked at the respiratory 
function effects of exposure to formaldehyde. Each reports a significant association of 
formaldehyde exposure with irritation of eyes and upper respiratory tract, but not all have found 
evidence of pulmonary function effects. A study by Alexandersson et al (1982) indicated that 47 
workers exposed to a mean concentration of 0.36 ppm (0.04 to 1.25 ppm) formaldehyde had 
symptoms of upper respiratory irritation and eye discomfort during their workshift. 
Alexandersson and Hedenstiema (1988) studied 38 workers exposed to a mean concentration of 
0.3 ppm with a peak of 0.5 ppm formaldehyde during an 8-hour workshift. The authors reported 
that reductions in Forced Vital Capacity (FVC) and First Second Forced Expiratory Volume 
(FEV,) were found in exposed carpentry workers after two exposure-free days. However, the 
deviation in FVC and FEV, in exposed workers could not be correlated to either peak exposures 
or an index of chronic exposure calculated as the mean exposure divided by the length of 
employment period. The authors argued that this cross-sectional study may have underestimated 
the exposure-response relationship because the most sensitive workers may have changed jobs 
and were no longer exposed to formaldehyde and solvents in their new occupations. 
Alexandersson and Hedenstiema (1989) conducted a five-year follow-up study for the carpentry 
workers exposed at the concentrations levels of 0.25 to 0.58 ppm formaldehyde. The authors 



6 



compared the lung function of the exposed employees to that of 20 unexposed workers. Eye and 
throat irritation and chest tightness was significantly more common in the exposed carpentry 
workers than in the controls. Reduced FEV, and increased closing volume as percentage of FVC 
were found in the exposed workers. The lung function of formaldehyde exposed particle board 
workers was evaluated by Malaka and Kodama (1990). Ninety-three workers exposed to a mean 
concentration of 1.13 ppm (0.22 to 3.48 ppm) formaldehyde were compared to a control group of 
93 employees exposed to the concentration levels ranging 0.003 to 0.07 ppm. There were no 
significant differences in smoking habits, age, height, and weight between exposed and controls. 
After controlling for the confounding effect of dust, the authors found that formaldehyde 
exposure was associated with reductions in the baseline spirometric values. Three cases of 
chronic obstructive lung diseases were identified in the exposed group. Formaldehyde exposure 
was also related to a significant (P <0.05) increase in the symptoms of cough, phlegm, chronic 
bronchitis, asthma, and shortness of breath. The authors concluded that an average exposure 
concentration of 1.13 ppm formaldehyde was statistically significantly associated with the 
induction of symptoms of chronic obstructive lung disease in exposed workers. 

However, several other authors found no respiratory function effects of chronic 
formaldehyde exposures. Horvath et al. (1988) indicated that no significantly greater incidence of 
permanent respiratory impairment was found in a group of particle-board workers after 1 0 years 
of exposure to an range of 0.17 to 2.93 ppm (mean, 0.69 ppm) formaldehyde, compared to a 
control group of 254 food-processing workers. Kilbum et al. (1989) found no significant change 
in respiratory fimction among 280 histology technicians exposed at 0.2 to 1 .9 ppm formaldehyde. 
Uba et al. (1989) conducted a prospective epidemiologic study of pulmonary function and 
respiratory symptoms among 1 03 medical students exposed at an average concentration of less 
than 1 ppm, with peak levels of 5 ppm formaldehyde. Irritation of the eyes and respiratory tract 
among these students was associated with formaldehyde exposure over a 7-month period, but no 
significant changes in pulmonary function were found in this study. 

Formaldehyde is a known sensitizer for the skin (Moore and Ogrodnik, 1986, and WHO, 
1989, and OSHA, 1992). No thresholds for reduction of dermal, respiratory tract, or systemic 
sensitization have been reliably determined. Prolonged and repeated contact with liquid 
formaldehyde solutions can cause skin irritation or allergic contact dermatitis, including 
sensitization. Nordman et al. (1985) gave 230 patients a bronchial provocation test with 
formaldehyde. They found that 12 cases had positive results caused by specific sensitization to 
formaldehyde. Hendrick and Lane (1977) identified eight cases of occupational asthma among 28 
nursing staffs who used formalin to sterilize the artificial kidney machine. Hendrick et al. (1982) 
followed up the nurses with occupational asthma. They found that one nurse had not worked with 
formaldehyde since 1976 and had had no further symptoms. The nurse was tested with 7.2 mg/nv' 
formaldehyde in 1981 and no asthmatic response was provoked. However, the other nurses, who 
had continued to work with formaldehyde, continued to suffer intermittent attacks of asthma. 

Formaldehyde has also been classified as a weak mutagen by the 



7 



Carcinogenicity /Histopathology/Genotoxicity Panel of The Consensus Workshop (Koestner et al, 
1984). The Panel recognized that positive results for the mutagenicity of formaldehyde were 
obtained in a lethal animal test. The International Agency for Research on Cancer (lARC) (Kerns 
et al, 1983) has evaluated formaldehyde in short-term bioassays and concluded that there is 
sufficient evidence for the mutagenicity of formaldehyde in these predictive tests. 

The available animal and human toxicological data do not indicate that formaldehyde, by 
any exposure route, produces significant developmental and reproductive effects (Feinman, 1988 
and Gough et al., 1984). The NRC (1981) concluded that formaldehyde has not been found to 
have teratogenic effects in animals. Chronic toxicological studies failed to prove that 
formaldehyde had any adverse developmental or reproductive effect in animals or humans. 
However, Walsh et al. (1984) reported that the workers exposed to formaldehyde at 0.83 to 3.8 
ppm have menstrual disorders, pregnancy complications and low birth weight of their offspring. 
Shumilina (1975), and Olson and Dossing (1982) found a significant increase in menstrual 
disorders in women exposed to formaldehyde concentrations of 1.2 to 3.6 ppm and 0.4 mg/m^, 
respectively. Other studies by Gough et al., (1984) and Hemminki et al., (1982) showed no 
increase in menstrual disorders among women exposed to formaldehyde. 

The subchronic effects of formaldehyde on animals have been studied by Rusch et al. 
(1983). Monkeys, rats, and hamsters were exposed to 0.2, 1.0, an 3.0 ppm formaldehyde for 22 
hours/day, 7 days/week for 26 weeks. Squamous metaplasia in the nasal turbinate was observed 
in both monkeys and rats exposed to the 3 ppm concentration of formaldehyde. These changes 
were not seen in any of the other exposed groups. Beal (1984) conducted a literature review of 84 
articles concerned with health effects in both animals and humans from subchronic exposures to 
formaldehyde and concluded that the animal data showed a qualitative relationship between 
formaldehyde absorption and hepatotoxicity. 

Although the conclusion that formaldehyde is a probable human carcinogen has been 
reached by EPA and OSHA, the evidence for the carcinogenicity of formaldehyde is limited and 
controversial. Animal studies have found nasal cancers from exposure to formaldehyde. 
Swenberg et al (1980) reported carcinomas of the nasal turbinate in male and female F344 rats 
after inhalation exposures of approximately 15 ppm formaldehyde for 12 and 18 months. At 18 
months, the total tumor incidence was 18 percent. Skems et al. (1983) reported squamous cell 
carcinomas in the nasal cavities of rats and mice after inhalation exposures at 14.3 ppm of 
formaldehyde for 6 hours/day, 5 days/week for 24 months. Two rats exposed at 5.6 ppm also had 
squamous cell carcinomas in their nasal cavities. 

The ACGIH (1992) concluded that "current understanding of the biochemical mechanism 
of formaldehyde inhalation toxicology does not support the hypothesis that formaldehyde can 
initiate the processes of cancers at occupational exposures". However, there are several 
epidemiologic studies reporting formaldehyde as a human carcinogen (Olson et al., 1984, 
Brinton, et al.,1984, Stayner et al., 1988, and Sterling and Weinkam, 1988). The ACGIH (1992) 



8 



pointed out that these epidemiologic studies either exhibited confounding, ver>' small sample 
sizes, lacked quantitative exposure data, or had an inadequate statistical analysis and suggested 
that "further investigation of the carcinogenic effects of this chemical should extend beyond the 
respiratory system". 

Occupational Exposure in Funeral Services 

Besides formaldehyde and its polymers (paraformaldehyde and polyoxymethylene), a 
variety of chemicals may be contained in embalming fluids. These chemicals are employed in 
different solutions for different purposes. Tissue moisturizers contain glycerol, sorbitol, lanolin, 
and glycol. Smooth muscle relaxants are comprised of nitroglycerin, magnesium chloride, and 
tetrapotassium pyrophosphate. Bleaching and antiseptic agents include phenol. The chemicals of 
methyl red, congo red, sodium bicarbonate, sodium carbonate, potassium nitrate, magnesium 
sulfate, borax, sodium chloride, methanol, ethanol, and disodium phosphate are used in some 
cases (Levine et al, 1984). Arterial preservative fluids with a 4% formaldehyde concentration are 
usually used in embalming, but higher concentrations of formaldehyde are also employed in 
some cases. 

Kerfoot and Mooney (1975) surveyed formaldehyde exposures in six funeral homes in 
Detroit area. Air samples were collected under a variety of conditions. In the embalming rooms 
the average formaldehyde concentration was 0.74 ppm (0.25 to 1.39 ppm, with a peak of 5.26 
ppm. Eye and upper respiratory tract irritation in some employees was reported, but no 
correlation with the degree of formaldehyde exposure was noted in this study. 

Holness and Nethercott (1989) studied a group of 84 embalmers exposed to a mean 
concentration of formaldehyde of 0.36 ppm ( 0.08 to 0.81 ppm) and 38 controls exposed to a 
mean conceritration of 0.02 ppm formaldehyde. The authors reported that in a logistic regression 
analyses, in which current smoking was controlled for, the prevalence of nose and eye irritation 
in exposed group was statistically significantly increased over the control group (44% versus 
16% and 42% versus 21%, respectively). The exposed group consisted of inactive embalmers 
and active licensed embalmers. The authors found that eye irritation was more frequent in the 
group of active embalmers than inactive embalmers. However, the ACGIH ( 1992) concluded 
that "individual susceptibility to the irritating effects of airborne formaldehyde can decrease with 
repeated exposure". 

Levine et al (1983) conducted a study of mortality among licensed undertakers in 
Ontario, Canada in 1982. A cohort of 1,477 embalmers licensed between 1928 and 1957 and 337 
deaths prior 1978 were studied. The ratio of observed to expected deaths from each cause was 
expressed as the standard mortality ratio. No significant increase in mortality was observed for 
any cause of cancer among the embalmers. Walrath and Fraumeni (1983) compared the 
proportion of cancer deaths among the embalmers exposed to formaldehyde in New York State 



9 



with that in the general population. Approximately 1,132 deceased embalmers licensed in New 
York State between 1902 and 1979 were selected for the study group. Mortality from skin 
cancer was significantly elevated among the embalmers who had worked for more than 35 years. 
No different mortality ratio was observed for respiratory tract cancer or nasal cancer. 

Plunkett and Barbela (1977) conducted a survey of 57 embalmers in 20 funeral homes in 
California. The study indicated that nine had symptoms compatible with acute bronchitis, and 1 7 
had chronic bronchitis. Data on formaldehyde exposure levels, work practices, ventilation or 
frequency of exposure was not reported in the study. Levine et al (1984) conducted a study of the 
respiratory health effects of formaldehyde exposure on West Virginia morticians. Of 112 
licensed morticians attending a postgraduate course in the state, 1 05 provided responses to 
questionnaires and 99 took pulmonary function tests. The values of the tested group were 
compared to those of residential populations in Oregon and Michigan used as control groups. 
The investigators concluded that "long-term intermittent exposure to low levels of formaldehyde 
gas exerts no meaningful chronic effects on respiratory health". The "low levels of 
formaldehyde" in the Levine et al (1984) study were reported by Williams et al. (1984). Area and 
personal samples of formaldehyde exposures were conducted in funeral homes and among 
twenty-five embalmers. The concentrations of formaldehyde in personal samples in seven West 
Virginia funeral homes ranged from 0.4 ppm during the embalming of intact bodies to 2.1 ppm 
during the embalming of autopsied bodies. The overall average exposures in the funeral homes 
were 0.3 ppm and 0.9 ppm, respectively. 

Personal exposures to formaldehyde in mortuaries have been documented as 0.5 to 8.72 
ppm ( Williams et al., 1984, Moore and Ogrodnik, 1986, ACGIH, 1992, and Korczynski, 1994). 
During this project, air sampling was done in a Massachusetts funeral home during embalming. 
Four sampling methods were used: 1) Assay Badge (Assay Technology, Inc.. Palo Alto, CA), 2) 
Impingers (NIOSH 3500), 3) Sep-Pak Cartridge (Millipore Corporation, Milford, MA), and 4) 
3721 Monitor Badges (3M). A total of 16 samples, four samples for each method, were collected. 
The eight samples collected by Assay Badges and Sep-Pak Cartridges were analyzed using High 
Pressure Liquid Chromatography (HPLC) and the other eight samples were analyzed using 
UV/visible light spectrophotometry. The operation time of the embalming was about three 
hours. During sampling, the ceiling fan was turned on and the doors were closed. The averaged 
formaldehyde concentration of personal samples was 0.96 ppm. The formaldehyde area samples 
averaged 0. 1 5 ppm with a range of 0. 1 3 - 0. 1 9 ppm. 

Historical Profile of the Practice of Embalming in Funeral Service 

The practice of embalming, or preserving human remains, originated with the Egyptians 
during the period of the first dynasty. It is estimated to have begun before 4000 B.C. and 
continued on until A.D. 650 (McDonald, 1989). Theorists believe that the practice was religious 
in origin, and used as a means to prepare the dead for a new life after death. During this nearly 



10 



4000-year period of embalming a number of techniques were used. Before 3200 B.C., 
Egyptians used a very simple method. A dead body was placed in the fetal position (arms and 
legs folded), wrapped in cloth or straw mats, and placed in a shallow grave. The body was then 
covered with the sand and the grave filled. The body was preserved by drying. The most 
elaborate of these ancient embalming methods consisted of removal of the major organs and 
filling of the body cavity with herbs and other substances, including honey, wax, and spices. 
Afterward, they used "natron" (a mixture of sodium chloride, sodium sulfate, sodium carbonate, 
potassium sulfate and potassium nitrate) to dehydrate the body before the remains were wrapped 
up in many layers of linen cloths and resins. This complex mummification process took 
approximately seventy days. The second embalming method consisted of injecting cedar oil into 
the anus and stoppering the opening. The external body was then treated with natron to effect 
dehydration. After a period of time the oil was drained. The third less costly and time-consuming 
consisted of cleaning the body, drying with natron, and wrapping it up in linen. Embalming 
during the Middle Ages included evisceration, immersion of the body in spirits of wine, insertion 
of preservation herbs into incisions made in the fleshy parts of the body, and wrapping the body 
in waxed or tarred sheets (Mayer, 1990). 

During the fifteenth century interest in body preservation was increased, partly because of 
a desire to discover more about human anatomy. Leonardo da Vinci (1452-1519) outlined a 
method of venous injection to preserve the cadavers. Early embalming fluids contained mixtures 
of turpentine, camphor, lavender oil, vermillion (mercury sulfide), wine, rosin, and saltpeter 
(Mayer, 1990). In the late seventeenth century, Gabriel Clauderus introduced an embalming 
method using "balsamic spirit", which was produced by dissolving one pound of cream of tartar 
and a half-pound of "sal ammoniac" in six pounds of water. The body cavity was injected with 
this mixture, and then the body was immersed in this solution for six weeks. Afterward, the body 
was placed in the sun to dry. A method of arterial and cavity embalming via a mixture of 
turpentine and camphor was first described by William Hunter, a Scottish anatomist in the 
eighteenth century (McKone, 1994). Embalming in the United States began during the Civil War 
because it had become fashionable to have a "proper" mourning period before interment 
(Plimkett and Barbela, 1977, and McDonald, 1989). In 1850, a patent was granted to Frederick 
and Trump for a "reftigerator for corpses". Frederick and Trump's invention helped delay 
decomposition of body tissue, but it did not destroy harmful bacteria. This caused concern for 
sanitation. Accordingly, several formulations of embalming fluids were adopted for use as a 
disinfectant and a body preservative. These solutions often contained salts of heavy metals ( such 
as arsenic, antimony, lead, mercury, and copper). These embalming fluids also caused risks to 
human health. By the early 1 900's laws were passed banning the use of metal salts in embalming. 
Formaldehyde became the most common preservative in embalming fluids. The properties of 
formaldehyde as a tissue fixative were discovered by accident in 1893 by Ferdinand Blum (1865- 
1959). Blum conducted a research project on the antiseptic properties of formaldehyde. While 
working with a 4 percent aqueous solution of formaldehyde, Blum found that his wet fingers 
became stiff. After he published his finding, formaldehyde found widespread use as a tissue 
preservative. Today, federal, state, and local codes regulate the practice of embalming human 



11 



remains, and remains must be embalmed with a formaldehyde solution before burial, even 
before cremation in some situations (Plunkett and Barbela, 1977 and McDonald, 1989). 

Embalming is regulated principally by the legislature of the individual states (Mayer, 
1990). In Massachusetts, two principal agencies have governed health care services and the 
disposition of dead human bodies. The two Massachusetts agencies are the Department of Public 
Health (Bureau of Health Statistics, Research and Evaluation) and the Board of Registration in 
Embalming and Funeral Directing. These two agencies promulgate regulations and enforce the 
statutory laws and regulations regarding the disposition of dead human remains. According to 
the Massachusetts regulation of 239 CMR (Board of Registration in Embalming and Funeral 
Directing, 1993), embalming a human dead body is required and permission for burial or 
transportation should be obtained from the two agencies. The 239 CMR 3.10 (2) states: 

" , sufficient preservation must be applied 

to guarantee temporary protection against excessive 
decomposition under the following conditions: 

A body dead of a disease or cause not dangerous 
to public health shall not be : 

(a) Removed, except in an approved funeral service 
vehicle with the personal attendance in the vehicle of 
person registered by this Board. 

(b) Transported on or through a public street or 
highway, or shipped by railway or air, unless 

1 . Embalmed by a registered embalmer who shall 
thoroughly disinfect it, and perform arterial and cavity embalming. 

2. If not so prepared as provided in 239 CMR 3.10(2)(b)l., 
and the body is to be buried or cremated within the Commonwealth 
within fifty (50) hours of removal from the place of death, and 
without viewing, then it shall be prepared by a registered embalmer 
by thorough washing, disinfecting and sanitizing, closing all orifices 
with treated absorbent cotton, enveloping the entire body with 
clean sheeting, or with provided clothing, so there shall be no 
offensive leaking or odors from the body before burial, cremation 
or other disposal within the fifty (50) hour period. 

3. If none of the above, refrigeration will be used in a unit so 
designed as to accept dead human bodies and retard decomposition 
by maintaining 34^^ ~39"F temperature. 

4. Bodies prepared as in 239 CMR 3.10(2)(b)2. or 3. will not be 
shipped by rail or air unless encased in a sealed casket or other 
air-tight container." 

Section 3 . 1 1 ( 1 ) of the law: 



12 



" , no burial or transportation permit shall be issued to 

anyone other than a funeral director registered and licensed 
under the laws of Massachusetts." 

In summary, the law requires that the dead human body has to be embalmed if viewing 
or an open casket funeral will be held in Massachusetts, otherwise it has to be buried or cremated 
within fifty (50) hours of removal from the place of death, without viewing or open casket 
funeral. If an embalming is performed for viewdng or funeral, thorough disinfection and arterial 
and cavity embalming is required. Only a registered and licensed funeral director can perform 
embalming, body transportation or burial services within the Commonwealth of Massachusetts. 

Two federal agencies have also regulated the activity of funeral homes. The Federal 
Trade Commission (FTC) has established regulations that require the funeral director: 1 ) to fully 
explain the necessity and purpose of embalming, as well as other funeral services, 2) to get 
permission for the embalming, and 3) to provide a full disclosure of costs for services performed 
in the transportation, handling, and preparation of the dead. The Occupational Health and Safety 
Administration (OSHA) has set standards regulating the safety and health of employees in the 
work area of funeral homes. The OSHA Permissible Exposure Limit (PEL) for eight-hour-time- 
weighted average exposure formaldehyde is 0.75 ppm. This standard was adopted in 1992. The 
American Conference of Governmental Industrial Hygienist (ACGIH, 1992) published an 
intended change to the Threshold Limit Value (TLV) for formaldehyde in 1989. This was based 
on evidence of irritation in humans exposed to formaldehyde, rodent data, and inadequate human 
cancer epidemiological studies. In 1992, the ACGIH lowered the level of TLV from 1.0 ppm to 
0.3 ppm Time-Weighted Average (TWA)-ceiling for formaldehyde. 



IV. EMBALMING PROCESS DESCRIPTION 

During embalming, the human body is disinfected, preserved, and restored in preparation 
for funeral services. During the course of work embalmers are exposed to formaldehyde and its 
polymers, which constitute the primary active ingredients of embalming fluids, jellies, and 
powders. While various preservation materials have been used through the centuries it was not 
until 1 900 that formaldehyde became cheap enough to permit its common use in embalming 
fluids. Some state laws now require the inclusion of formaldehyde in embalming fluid 
formulations ( Bjorkman et al., 1982). Massachusetts does not have such a requirement. 

Procedures and Processes of Embalming 

In embalming, the actual procedure used and the time required depend on the condition of 
the body to be embalmed. Two important categories of embalming practice can be distinguished 



13 



in relation to exposure assessment: the embalming of intact bodies and the embalming of 
autopsied bodies. Formaldehyde exposures in embalming autopsied bodies are more intense 
because it requires a longer time and higher concentrations of formaldehyde to embalm autopsied 
bodies. Autopsied bodies usually comprise only a minority of the total bodies embalmed. The 
actual proportion varies in different locations and with different clientele (Levine et al, 1984, 
Williams et al, 1984, and McDonald, 1989). 

For a normal intact body, the average embalming time is approximately two hours 
(Willimas et al, 1984, Levine et al, 1984, and McDonald, 1989). The embalmer places the dead 
body onto a metal embalming table. Embalming fluids are diluted with water to a formaldehyde 
concentration of four percent, with higher concentrations used in cavity fluids and for treating 
problem cases (Levine et al, 1984 and Cocanour, 1993). The diluted formaldehyde fluid is 
injected into a femoral artery and vein, through which the fluids circulate throughout the vascular 
system and diffuse into the tissues, and then, the blood is drained. 

Thoracic and abdominal viscera can not be embalmed by arterial infusion because of the 
low infusion pressure and the rapid post-mortem deterioration of organ capillaries. Thus, 
embalming of the viscera is accomplished by inserting a trocar to puncture the internal organs, 
sucking the blood and tissue fluids from the thoracic and abdominal cavity, and instilling a bottle 
of preservative fluid called "cavity fluid", which contains a more concentrated solution of 
formaldehyde and phenol. Aspiration and embalming of the body cavities is completed in several 
minutes (Williams et al, 1984 and McDonald, 1989). 

Levine et al (1984) reported approximately three hours were required for embalming an 
autopsy case. With autopsied bodies, the thoracic and abdominal vasculature have been disrupted 
by incision of the aorta and removal of the viscera. Therefore, during the autopsy, the viscera are 
washed and bathed outside the body in a plastic bag, into which a bottle of highly concentrated 
preservative fluid is poured. Since arteries and veins are severed at autopsy, each limb and each 
side of the head must be embalmed separately by injecting preservative fluid. Embalming fluids 
are injected and accumulate at the body cavities, and are finally removed by suction. Interior 
cavity surfaces are coated with embalming jelly and sealed with hardening compound—a 
sawdust-like material containing paraformaldehyde. This dusting procedure lasts about ten 
minutes (Willimas et al, 1984). The viscera are then returned to the body and the body is closed. 

Estimation of Facilities and Working Population 

Data obtained from the Massachusetts Board of Registration in Embalming and Funeral 
Directing (1994) showed that in 1993 there were 950 funeral homes distributed throughout the 
state, which were staffed with 2,400 licensed morticians (Carow, 1993). During site visits and 
through interviews with morticians, it was found that each of the licensed morticians has at least 
one assistant, who is not licensed. Therefore, it is estimated that there are at least 4,800 



14 



employees participating in the embalming process at the 950 funeral homes in Massachusetts. 

The National Funeral Director Association (NFDA) conducted a national survey of 
funeral services in 1992 (NFDA, 1993). The survey showed that in the majority (78.3%) of the 
deaths funeral services were held while 7.1% of the deaths were treated with direct disposition. 
The survey also indicated that nationwide, 78.1 % of the dead had ground burial and that 19% 
were disposed of with cremation. Brelis (1994) reported that in 1992, 18.1% of those who died 
in Massachusetts were cremated. Data from the state Department of Public Health (1994) showed 
that in 1992 there were 53,804 deaths reported in Massachusetts. For each embalmed body 
approximately five gallons of embalming fluid are consumed (Richins et al., 1963, Mayer, 1990 
and Carow, 1993). We assumed the 7.1% deaths with direct disposition are not embalmed. 
Based on this data, it is estimated that approximately 49,984 bodies are embalmed in 
Massachusetts each year, using approximately 249,920 gallons of embalming fluid. Assuming 
that 80% of the embalming fluids used are diluted to contain 4% formaldehyde for arterial 
injection and that 20% of the fluids contain 37% formaldehyde for cavity injection, this translates 
to approximately 180,163 pounds (26,492 gallons) of formaldehyde consumed each year by 
funeral homes in Massachusetts. 



V. OPTIONS FOR FORMALDEHYDE USE REDUCTION 

A comprehensive approach should be adopted for formaldehyde use reduction in 
mortuaries. This comprehensive approach could involve: 

1 . Modification of societal behaviors and legislative changes ; 

2. Development of alternative technologies for preservation of the human body; 

3. Substitution or reduction of formaldehyde use in embalming; 

4. Minimization of formaldehyde release during embalming. 

1. Modification of Societal Behavior and Legislative Changes 

a) Changes in legislation requiring embalming. 

b) Changes in human behaviors around death and funeral services. 

To express one's mourning for the dead, a memory rite is held. Humans usually use this 
time to say good-bye to the person who has just passed away. These activities are understood 
because we are humans. However, is it necessary to develop such elaborate funeral services. 



15 



which include the use of fashionable clothes, expensive caskets, and extensive work by 
beauticians on the corpse ? Is it necessary to embalm human remains when the mourning rite is 
held within the short time period (two days), or for cremation or immediate burial? 

First of all, the associated legislation mandates embalming the dead body if a funeral 
service with viewing or open casket is arranged in Massachusetts. This regulation is concerned 
with public health. However, a dead body without an infectious disease will not cause a health 
risk to the public if buried or cremated within fifty (50) hours after death. The tissues of a dead 
body begin to be decomposed after three days under normal conditions. This means that it is not 
necessary to embalm the dead body when the morning rite is held within two days, or for 
cremation or immediate burial even if an open casket viewing is desired. To change the 
associated legislation will result in a reduction of formaldehyde use in fiineral service in 
Massachusetts. 

Cannon (1989), an anthropologist, conducted a comparative historical analysis of 
mortuary behavior in different cultures in order to find out why himians use mortuary expression 
so heavily. He believed that people had come to use mortuary services as a competitive social 
and economic display. This competitive use of mortuary expression has resulted in the mortuary 
industry providing and encouraging more elaborate services. 

Perhaps societal pressures can also be brought to bear in promoting certain burial 
procedures as "environmentally sound". Many people who are ecologically minded believe that 
cremation is desirable because the human remains take up less space. Cremation is very common 
in Asia, where land is at a premium. In the urban areas of China, the cremation rate is 99 percent 
and in Japan, the rate is 98 percent (Brelis, 1 994). Cremation is also an economically sound 
alternative. A basic cremation can be as little as $500. However, a ground burial can cost more 
than $5,000. A typical wooden casket costs about $4,000, embalming charges $300, cemetery 
prices range from $350 to $1,050, and the average price of a grave is $650 (NFDA, 1992). Thus, 
environmental and economic pressures may influence human behavior in the selection of 
mortuary treatment, at least in foregoing embalming preparation, and perhaps in choosing 
cremation rather than groimd burial. 

2. Alternate Technologies for Preservation of the Human Body 

a) Changes in the burial procedures. 

b) Disinfection of the body surface with an alcohol solution and use of personal protective 
equipment for funeral service employees. 

c) Refi^igerated storage. 

d) Use of enclosed container or closed casket. 

At present, there are many techniques available to preserve dead bodies without 



16 



embalming. If funeral homes encouraged burial within a short time period (two days) after 
death, simple disinfection of bacteria on the surface of the human body could be employed. It is 
not necessary to spend $300 to embalm the body for a funeral service that will occur in a short 
time. 

If it is essential to keep the human remains for a longer time period, the unembalmed 
body can be kept in refrigerated storage. In the case of a body dead of a non-infectious disease, a 
closed casket funeral service can currently be held without embalming if the human body is 
properly disinfected on the surface by funeral service employees wearing appropriate personal 
protective equipment. 

3. Substitution or Reduction of Formaldehyde Use in Embalming 

a) Ethyl alcohol and polyethylene glycol (Kryofix). 

b) Glutaraldehyde. 

c) Phenoxyethanol. 

An alternative to formaldehyde in tissue preservation was introduced by Boon et al. in 
1992 ( Boon et al., 1992). Kryofix (Merck, product no 521 1) which was developed in the 
Netherlands, is a mixture of ethyl alcohol and polyethylene glycol without aldehydes. The 
effects of Kryofix on tissue fixation were compared with those of formaldehyde in a pathology 
laboratory. It is said to be pleasant to use. The fixation time of Kryofix was shorter than 
formaldehyde and preservation excellent. However, these results were achieved with small tissue 
samples in a pathology laboratory. Thus, experience with large amounts of tissue and whole 
bodies is needed to reach reliable conclusions regarding substitution of this material in 
embalming. According to the OSHA's definition of toxicity as listed in the Hazard 
Communication Standard (OSHA, 1994), neither ethyl alcohol or polyethylene glycol are toxic 
chemicals (NIOSH, 1986 and Lewis, 1993). Boon et al (1992) did not discuss the cost of this 
fixative. 

Glutaraldehyde may be used as an alternative to formaldehyde in embalming fluids. 
Glutaraldehyde was first used as an embalming and fixative in embalming a dead human body in 
1955 (Mckone, 1994). Glutaraldehyde is a five-carbon, straight-chain dialdehyde chemical. The 
commercial product of glutaraldehyde is a stable 25% aqueous solution which has a mild odor 
and a light color. The chemical reaction of glutaraldehyde with tissue proteins is similar to 
formaldehyde. There are many factors that may affect the rate of tissue preservation using 
glutaraldehyde. A high concentration of glutaraldehyde may enhance the protein fixation in a 
dead human body. The range of 1.0 to 1.5 percent (aqueous) may be the optimum concentration 
for embalming. Since a slightly alkaline solution can obtain better fixation of tissue proteins at 
room temperature, 2% alkalinized glutaraldehyde solutions are often adopted for embalming 
preparations. The reaction of an aqueous solution of glutaraldehyde with water may produce a 



17 



variety of byproducts such as 4-formyldec-4-enedial, 2,6-dihydroxyoxane, and Poly(2,6- 
dihydroxyoxane). These byproducts may reduce glutaraldehyde's effectiveness as a fixative agent 
in embalming. Proper purification and storage of the aldehyde monomer is, thus, very important. 
Compared to formaldehyde, glutaraldehyde can react with tissue proteins over a wide pH range. 
Protein binding with glutaraldehyde is much stronger and the resulting protein-aldehyde products 
are more stable. When combining with proteins and tissue, glutaraldehyde changes the nature of 
the proteins and makes them unsuitable as food for bacteria. Glutaraldehyde diffuses and 
penetrates into tissue cell more evenly than formaldehyde. Thus, when mixed with coloring 
agents in the embalming fluid, the glutaraldehyde solutions will provide more "natural" 
coloration for funeral service. Glutaraldehyde-based solutions have been considered a more 
efficient and effective disinfectant than formaldehyde (Mayer, 1990 and McKone, 1994). 
However, the cost of glutaraldehyde is 4—5 times more expensive than that of formaldehyde 
(McKone, 1994). 

In terms of toxicity, both formaldehyde and glutaraldehyde are skin , eye, and the 
respiratory tract irritants when inhaled, but glutaraldehyde is a mild skin and respiratory irritant 
(Hathaway et al., 1991 and Lewis, 1993). Glutaraldehyde was recently reported to cause 
sensitization. Hathaway et al (1991) reported that glutaraldehyde caused allergic contact 
dermatitis in hospital workers. Weinert et al ( 1 994) reported that 23 employees in a hospital were 
sensitized at glutaraldehyde concentrations below OSHA's ceiling exposure limit of 0.2 ppm. 
Based on the NIOSH Registry of Toxic Effects of Chemical Substances (1986) and Hathaway et 
al (1991), the toxicity of glutaraldehyde was low and mild. However, glutaraldehyde lacks the 
odor of formaldehyde. To date, there is no data indicating that chronic exposure to 
glutaraldehyde can cause any adverse developmental and reproductive effect or cancer in animals 
or humans. 

Phenoxyethanol as a "nontoxic" preservative for reduction of formaldehyde exposures 
was studied by Frolich et al, (1984) and Wineski and English (1989). The modified 
phenoxyethanol techniques in the Wineski and English study involved two steps: (1) utilizing 
lower volumes and lower concentrations of formaldehyde in embalming fluids. 1 .5 to 2.0% 
formaldehyde fixation was used in this study; (2) the embalmed cadaver was then immersed in 
approximately 200 liters of 1 % phenoxyethanol solution for preservation. The authors reported 
that the results with phenoxyethanol were excellent and tissue preservation was outstanding 
(Wineski and English, 1989). This modified phenoxyethanol technique required a significantly 
shorter embalming process using lower volumes and lower concentrations of formaldehyde. 
These techniques greatly reduced the use and exposure of formaldehyde and other chemicals in 
the embalming operation, and decreased the tissue saturation concentration of embalming fluids. 
However, the technique is most relevant for cadaver preservation for teaching laboratories 
(Wineski and English, 1989). 

Despite the advantages of some of the substitutes for formaldehyde the typical four 
percent solution of formaldehyde continues to be used by most morticians. Mckone (1994) 



18 



claims that laboratories continue to use a four percent solution of formaldehyde in tissue 
preservation, not because of any evidence supporting the conclusion that a four percent solution 
is optimal, but because that was the dilution used by Blum in 1893. In interviews with funeral 
directors and embalming fluid manufacturers, the consistent reason given for the continued use 
of formaldehyde was its century old track record of successful and consistent embalming results. 
Although there are other fixatives commercially available, formaldehyde continues to be the 
most popular for embalming. This indicates that consumer loyalty plays an important role in the 
choice of embalming fluids. It will not be easy to convince funeral directors that they should 
switch to another embalming fluid especially if that fluid is more expensive. However, pressure 
from mortuary employees exposed to formaldehyde and from governmental agencies limiting the 
use of formaldehyde could be an important force for change in embalming solution formulation. 



Minimization of Formaldehyde Release 

Minimization of formaldehyde release plays an important role in reducing formaldehyde 
exposure and therefore its use in embalming services. Good maintenance and work practice are a 
very important aspect of minimizing formaldehyde release in embalming. Figure II describes 
detailed measures for reducing formaldehyde use in embalming. In Figure II, the process of 
embalming is divided into four steps— embalming preparation, artery injection, cavity injection, 
and cleanup. In embalming preparation, dilution of the embalming solutions and filling of the 
embalming machine should be handled carefully. Spills and overflow should be avoided. The 
embalming machine should always be covered and enclosed. Disinfection of the surface of the 
body should be performed by swabbing with a disinfectant solution. A 75% alcohol solution is 
strongly recommended as a disinfectant solution in this step. The artery injection step produces 
high exposure to formaldehyde. All body orifices and openings should be sealed before solution 
injection. The pressure and rate of flow for the embalming injection should be correctly selected. 
Leakage and overflow of the embalming fluids should be avoided. Over-injection of the 
embalming fluid into the body must be avoided. The drainage outlet should be connected to a 
closed container. During cavity injection, a minimal concentration of formaldehyde in the 
embalming solution should be selected and a minimal amount of fluid used. After cavity fluid 
injection, the openings in the body should be closed with a trocar button and the body should be 
covered by a plastic bag. In the last process, the cleanup step, the body should remain tightly 
covered with plastic bag. The remaining solution in the embalming machine should be kept in a 
closed container. 



VI. CONCLUSIONS AND RECOMMENDATIONS 

Formaldehyde may still be the most popular fixative used in embalming in the United 
States. The widespread use of formaldehyde fluid causes numerous health concerns because it 



19 



may cause irritation, immunologically mediated sensitization, contact dermatitis, respiratory 
function changes, and cancer. In 1992, the standard for occupational exposure to formaldehyde 
was lowered by the Occupational Safety and Health Administrations because the substance was 
linked to cancer of the lung and nasal passages in humans. This action brought formaldehyde to 
the attention of the nation. As users of formaldehyde, funeral homes are affected by those 
regulatory changes. Formaldehyde is a listed toxic chemical under the Massachusetts Toxics Use 
Reduction Act, and funeral homes are required to report use and emission data and to prepare a 
TUR plan if they exceed use thresholds. 

To reduce formaldehyde use in embalming, a comprehensive approach should be 
adopted. Such an approach includes the modification of himian mortuary behavior, the use of 
alternate techniques for preservation of the human body, the substitution of formaldehyde in 
embalming fluids, and the minimization of formaldehyde release during embalming. 

Modification of human mortuary behavior could have a large impact on formaldehyde 
use reduction in funeral services. Mortuary as a social phenomenon existed before 4000 B.C.. It 
developed as a common process of human social and expressive behavior. Changes in both 
mortuary behavior and the associated legislation which mandates embalming would have the 
greatest potential for formaldehyde use reduction. The alternative of quick burial (within two 
days) without embalming may reduce formaldehyde use in the funeral industry. This alternative 
needs only disinfection with alcohol on the surface of a dead body. Cremation may be the 
optimal option for major formaldehyde use reduction in the funeral industry. A dead body does 
not need to be embalmed for cremation. Brelis (1994) reported that cremations are becoming 
increasingly acceptable around the nation. The cremation rate is 35 percent in Florida, and on the 
West coast 42 percent of deaths are cremated due to the Pacific rim influence. Many Asian 
religions favor cremation, and in Japan the cremation rate is 98 percent. However, in the United 
States only 19 percent of all deaths were cremated nationwide and in 1992 only about 18 
percent of Massachusetts deaths were cremated (Brelis, 1994). 

Substitution of a relatively non-toxic mixture of ethyl alcohol and polyethylene glycol 
fixative (Kryofix) for formaldehyde may be possible once consistent reports of whole body 
preservation are published. Glutaraldehyde may also be used as a substitute for formaldehyde in 
embalming fluids. However, its health effects, especially sensitization should be further studied 
before glutaraldehyde is used as a non-toxic substitute for formaldehyde in embalming. Reducing 
the concentration of formaldehyde in embalming fluid or improving embalming procedures 
would have the least impact on formaldehyde use reduction in embalming. However, even these 
modifications would be helpful in cases where other means of TUR are not available or possible. 



20 



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